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Indian River <br />45th Street <br />0 <br />RFQ # 2018012 <br />X Neither the entity submitting this sworn statement, nor any officers, directors, executives, <br />partners, shareholders, employees, members, or agents who are active in management of the <br />entity, have any relationships as defined in section 105.08, Indian River County Code, with any <br />County Commissioner or County employee. <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />Name of Affiliate <br />or entity <br />STATE OF Florida <br />Name of County Commissioner <br />or employee <br />Relationship <br />is (Signature) <br />2 <br />(Date) <br />COUNTY OF Indian River �f+- <br />The foregoing instrument was acknowledged before me this." a day of �C'&A( f- 20_LZ by _ <br />Stephen E. Moler w�sonally know to me r who has produced <br />as identification. <br />Mj MASTELLER & MO] <br />M - CIVIL ENGINEERS - <br />NOTARY PUBLIC <br />Y� <br />SIGN: tiyt a� <br />PRINT: <br />Notary Public, State at large <br />My Commission Expires: jalOq/i8 <br />(Seal) <br />CINDY L. BASS <br />C"Wissim # FF 174661 <br />ExPka Decm*v9, 2018 <br />Page 11 of 11""mew <br />" <br />g. DISCLOSURE & LICENSES I PAGE 2 <br />